The Committee for Tactical Emergency Casualty Care (C-TECC), which was developed to bring the TCCC level of care to civilian first responders, has now introduced guidelines for first responders that aren’t trained to the level of an EMS provider. As stated by E. Reed Smith, MD and Nelson Tang, MD, co-chairmen of the C-TECC, “specific items, like basic and advanced life support interventions have been removed to both reflect the proper scope of the non-EMS end user and to avoid confusion. It remains the opinion of the Board of Directors that civilian first responders should act only within their allowed scope.”

This is a big announcement and it’s great to see guidelines like these developed for those not trained as EMS Providers, like some Law Enforcement Officers and Firefighters.

We’ve posted these new guidelines below and also have them available in .pdf format here to download.

DIRECT THREAT CARE (DTC) / HOT ZONE Guidelines

Mitigate any threat and move to a safer position (e.g. Return fire, utilize less lethal technology, assume an overwhelming force posture, etc.).

Recognize that threats are dynamic and may be ongoing, requiring continuous threat assessments.

Direct the law enforcement/first responder casualty to stay engaged in tactical operation if able and appropriate.

Extract casualty to a safer position:

Instruct the casualty to move to a safer position and apply self-aid if capable.

If the casualty is responsive but cannot move, a rescue plan should be devised and implemented.

If a casualty is unresponsive, weigh the risks and benefits of an immediate rescue attempt in terms of manpower and likelihood of success. Remote medical assessment techniques for survivability should be considered.

Stop life threatening external hemorrhage if present and reasonable depending on the immediate threat, severity of the bleeding and the extraction distance to safety. Consider moving to safety prior to application of the tourniquet if the situation warrants.

INDIRECT THREAT CARE (ITC) / WARM ZONE Guidelines

Any casualty with a weapon should have that weapon made safe and secured once the threat is neutralized and/or if mental status is altered.

Bleeding:

Assess for and control any unrecognized major bleeding:

Use a tourniquet or an appropriate pressure dressing with deep wound packing (either plain gauze or, if available, hemostatic dressing to control life- threatening bleeding in an extremity or a junctional area:
– Apply the tourniquet over the clothing as proximal – high on the limb – as possible, or if able to fully expose and evaluate the wound, apply directly to the skin at least 2-3 inches above wound (DO NOT APPLY OVER THE JOINT).
– For any traumatic total or partial amputation, a tourniquet should be applied as high on the extremity as possible regardless of bleeding.

If available, immediately apply a junctional tourniquet device for anatomic junctional areas where bleeding cannot be easily controlled by direct pressure and hemostatics/dressings.

Reassess all tourniquets that were hastily applied during Direct Threat/Hot Zone Care.

Evaluate the wound for continued bleeding or a distal pulse in the extremity.
– If there is continued bleeding or a distal pulse is still present, either tighten the existing tourniquet further or apply a second tourniquet, side- by-side and, if possible, proximal to the first, to eliminate the distal pulse.

If possible, mark all tourniquet sites with the time of tourniquet application.

Airway Management:

If the casualty is unconscious or is conscious but unable to follow commands:

Clear mouth of any foreign bodies (vomit, food, teeth, gum, etc).

Apply basic chin lift or jaw thrust maneuver to open airway.

Consider placing a nasopharyngeal airway.

Place casualty in the recovery position to maintain the open airway.

If the casualty is conscious and able to follow commands:

Allow casualty to assume position of comfort, including sitting up. Do not force to lie down.

Breathing:

All open and/or sucking torso wounds should be treated by immediately applying a vented or non-vented occlusive seal to cover the defect.

Monitor any casualty with penetrating torso trauma for the potential development of a tension pneumothorax. Most common presentation will be penetrating chest injury with subsequent increasing shortness of breath and difficulty breathing and/or increasing anxiety/agitation.

If tension pneumothorax appears to be developing, removing the occlusive dressing and/or “burp” the chest seal.

Casualties with concern for developing tension pneumothorax should be prioritized for evacuation to higher level of care.

Shock Management/Resuscitation:

Assess for hemorrhagic shock

Altered mental status (in the absence of head injury) and weak or absent peripheral pulses are the best field indicators of shock.

If not in shock:

Casualty may drink if conscious, can swallow and there is a confirmed delay in evacuation to care.

If in shock:

Prioritize for rapid evacuation any patient, especially those with penetrating torso injury, displaying signs of shock.

Burn patients are more susceptible to hypothermia – minimize heat loss as above.

Communicatewith the casualty if possible.

Encourage, reassure and explain care.

Cardiopulmonary Resuscitation:

CPR within this phase of care for victims of blast or penetrating trauma who have no pulse, no ventilations and no other signs of life will likely not be successful and should not be attempted.

In other circumstances, performing CPR may be of benefit and may be considered in the context of the operational situation.

Documentation of Care:

Communication of assessments and treatments rendered should be passed along with the casualty to the next level of care. This should be documented on a simple standardized casualty care card with the casualty to the next level of care.

EVACUATION CARE (EVAC) / COLD ZONE Guidelines

Reassess all interventions applied in previous phases of care.

If multiple wounded, perform primary triage for priority and destination of evacuation to a higher level of care.

Airway Management:

The principles of airway management in Evacuation Care / Cold Zone are similar to that in ITC / Warm Zone.

If the casualty is unconscious or is conscious but unable to follow commands:

Clear mouth of any foreign bodies (vomit, food, teeth, gum, etc).

Apply basic chin lift or jaw thrust maneuver to open airway.

Consider placing a nasopharyngeal airway.

Place casualty in the recovery position to maintain the open airway.

If the casualty is conscious and able to follow commands:

Allow casualty to assume position of comfort, including sitting up. Do not force to lie down.

Breathing:

All open and/or sucking chest wounds should be treated immediately by applying a vented or non-vented occlusive seal to cover the defect. Monitor the casualty for the potential development of a subsequent tension pneumothorax.

Reassess casualties who have had chest seals applied. Any developing tension pneumothorax should be treated as described in ITC / Warm Zone.

If available, administration of oxygen may be of benefit for all traumatically injured patients, especially for the following types of casualties:
– Chest injuries
– Torso injuries associated with shortness of breath
– Unconscious or altered mental status
– Post-blast injuries
– Casualty in shock
– Casualty at altitude

Bleeding:

Fully expose wounds to reassess for and control any unrecognized major bleeding:

Use a tourniquet or an appropriate pressure dressing with deep wound packing (either plain gauze or, if available, hemostatic gauze) to control life-threatening bleeding in an extremity or a junctional area:
– Apply the tourniquet over the clothing as proximal– high on the limb– as possible, or if able to fully expose and evaluate the wound, apply directly to the skin 2-3 inches above wound (DO NOT APPLY OVER THE JOINT).
– For any traumatic total or partial amputation, a tourniquet should be applied regardless of bleeding.

If available, immediately apply a junctional tourniquet device for anatomic junctional areas where bleeding cannot be easily controlled by direct pressure and hemostatics/dressings.

Reassess all tourniquets that were hastily applied during prior phases of care.

Evaluate the wound for continued bleeding or a distal pulse in the extremity.
– If there is continued bleeding or a distal pulse is still present, either tighten the existing tourniquet further or apply a second tourniquet, side-by-side and, if possible, proximal to the first, to eliminate the distal pulse.

Clearly mark all tourniquet sites with the time of tourniquet application.

Shock Management/Resuscitation:

Re-assess for developing hemorrhagic shock

Altered mental status (in the absence of head injury) and weak or absent peripheral pulses are the best field indicators of shock.

Utilize additional medical assessment and monitoring equipment that may be available in this phase.

If not in shock:

Casualty may drink if conscious, can swallow and there is a confirmed delay in evacuation to care.

Complete full front and back re-assessment checking for additional injuries. Inspect and dress known wounds that were previously deferred.

Frequently re-check the casualty for any changes in condition. Worsening status at any point should prompt priority evacuation. Consider alternative methods of transportation to definitive medical care if traditional methods delayed or unavailable. Ensure coordination of patient distribution to avoid overwhelming any one medical receiving facility.

Burns:

Stop the burning process.

Cover burns with loose dry dressings if available. Clean, dry sheets are effective for casualties with large area burns.

Large area burns and signs of significant airway burns or smoke inhalation (e.g. singed facial hair, soot/burns/swelling around the nose or mouth) should be prioritized for rapid evacuation. Consider alternative methods of transportation to definitive medical care if traditional methods delayed or unavailable. Ensure coordination of patient distribution to avoid overwhelming any one medical receiving facility.

Burn patients are more susceptible to hypothermia – minimize heat loss as above.

Threat mitigation techniques will minimize risk to casualties and the providers. These should include techniques and tools for rapid casualty access and egress.

Triage should be deferred to a later phase of care. Prioritization for extraction is based on resources available and the tactical situation.

Minimal trauma interventions are warranted during this phase.

Consider bleeding control. a. Tourniquet application is the primary “medical” intervention to be considered. b. For response personnel, tourniquet should be readily available and accessible with either hand.

Are you getting more than 14¢ of value per day from ITS?

Thanks to the generosity of our supporting members, we’ve eliminated annoying ads and obtrusive content. We want your experience here at ITS to be beneficial and enjoyable.

At ITS, our goal is to provide different methods, ideas and knowledge that could one day save your life. If you’re interested in supporting our mission and joining our growing community of supporters, click below to learn more.